ED (Emergency Department) Sample Coded charts

Sample Coded chart 1

General
Chief Complaint: Altered Mental Status
Time Seen by Provider: 12/07/23 19:12
History Source: Patient
Mode Of Arrival: EMS
Presenting Limitation(s): No Limitations

– History of Present Illness
HPI narrative:

This is a 76-year-old male patient who presents to the emergency department tonight by ambulance  for evaluation of altered mental status that was witnessed by nursing home staff. According to EMS patient was supposedly lying in bed on his knees and hands. Patient at time of physical exam is alert and oriented x4. He denies any recent fever, dysuria, abdominal pain, nausea, vomiting, fatigue, headache, recent incident, trauma, or decreased appetite. Patient history of dementia. Vital signs stable. Patient ambulatory to exam room off EMS stretcher. Patient sent for evaluation here in regards to unusual like behavior according to the nursing home staff.

Presents With Report/ Complaints Of: Reports: Altered Mental Status
Onset Of Symptoms: Just PTA
Duration: Reports: Now Resolved
Timing Confirmed By: Reports: Other – Nursing home facility
Severity At Onset: Mild
Severity At Present: 1
Baseline Prior To This Episode: Reports: A/O X4
Character At Present: Reports: Other – Alert and oriented x4
Prior Episodes: Occasional – 4/25/23
Exacerbating Factor(s): Reports: None
Relieving Factor(s): Reports: None
Context: Reports: Other – Presently unknown. Patient history of dementia
Risk Factor(s): Reports: COPD, Other – History of dementia
Treatment(s) PTA: Reports: None
Associated symptoms: Reports: Denies Other Symptoms

Review of Systems

Review Of Systems: Completed. All Systems Otherwise Negative

Constitutional
Constitutional Findings:
Neg: Fever, Chills, Weakness, Fatigue

Cardiovascular
Cardiovascular Findings:
Neg: Chest Pain

Respiratory
Respiratory Findings:
Neg: SOB

Gastrointestinal
Gastrointestinal Findings:
Neg: Abdominal Pain, Nausea, Vomiting, Diarrhea

Genitourinary
Genitourinary Findings:
Neg: Dysuria

Neurologic
Neurologic Findings:
Neg: Headache(s), Dizziness, Altered LOC

Past Medical/Family/Social Hx
Medical History: Reports: COPD, Dementia, Other
Smoking Status: Current Every Day Smoker

Physical Exam

General
General Appearance: Alert, No Acute Distress

Skin
Skin: Dry, Intact, Pink

Head
Head: Normocephalic, Atraumatic

Eye
Eye: PERRL
Pupil Size Right (mm): 3
Pupil Size Left (mm): 3
Pupil Description: Equal, Reactive

ENT
ENT: TM’s Clear, Oral Mucosa Moist

Neck
Neck: Supple, Trachea Midline

Chest Wall
Chest Wall: Normal Inspection, Symmetric Chest Wall Rise

Cardiovascular
Cardiovascular: Regular Rate, Normal Rhythm, Normal Peripheral Perfusion, S1, S2. Negative For: Murmur

Respiratory
Respiratory: Lungs CTA, Non-labored Respirations, BS Equal

Gastrointestinal
GI/Abdominal: Soft, Nontender, Normal BS

Back
Back: Normal ROM

Musculoskeletal
Musculoskeletal: Normal ROM

Neurological Exam
Neurological: A/O x4, CN II-XII Intact
Psychiatric: Cooperative, Appropriate Mood, Appropriate Affect

Altered Mental Status

MDM Narrative

Lab diagnostics reviewed with no acute findings. CT also also has no acute intracranial findings. X-ray clear. Patient remains alert and oriented x4. Ambulatory with no difficulty. Patient will be discharged back to nursing home.

Differential Diagnosis
Differential Dx: CVA, Dehydration, Other – UTI

Medical Records
MDM Medical Records Attestation: I reviewed the patient’s medical records.

Lab Data
MDM Lab Attestation statement: I reviewed the patient’s lab results.

Radiology Data
MDM Radiology Attestation Statement: I reviewed the patient’s radiology results.
Radiology type: CT
Chest Xray Interpretation: WNL, Interpretation By Radiologist
CT: W/O Contrast – head, Radiologist Interpretation
CT HEAD WITHOUT CONTRAST-

1. No CT evidence of acute intracranial process.

2. Prominent chronic central and cortical cysts involutional changes.

3. Primary chronic periventricular and deep cortical microangiopathic ischemic white matter changes.

4. Old lacunar infarct to the right basilar ganglia.

– Medication Given
Medications given: None

– Code Status
Code Status Discussion: Not discussed

Pulse Ox Data
MDM Pulse Oximetry Interpretation: Normal

Treatment Plan Discussion
Treatment plan discussed with:: No other provider

Sepsis Event Note

Evaluation
Sepsis screening result: No Definite Risk
Current stage of sepsis: Ruled Out

Disposition
Clinical Impression:
AMS (altered mental status)

Dementia

Disposition: Home, Self-Care/Family Care

Additional Instructions:
Please note that this emergency department visit only provided an initial, brief evaluation to determine if any life or limb threatening conditions exist. Your evaluation reveals nothing life or limb threatening, however, no test is perfect. Follow up with your primary care provider within 1-2 days. Return to the emergency department for worsening symptoms.

CPT code : 99285

70450 – CT head without contrast
71045 – Chest Xray

R41,82 – AMS

F03.918 – Dementia
J44.9 – COPD

Sample Coded chart 2

History Of Present Illness

General
Chief complaint: Abnormal Lab/Vital Signs
Time Seen by Provider: 03/25/22 17:08
History Source: Patient
Mode Of Arrival: Ambulatory
Presenting Limitation(s): No Limitations

History of Present Illness

Patient sent here from her pharmacy for high blood pressure. She states that they took her blood pressure with a wrist cuff and it was around 220/130. She was recently started on hydrochlorothiazide for her elevated blood pressure. On arrival here her blood pressure was 146/69.
Duration: Reports: Now Resolved
Risk Factor(s): Reports: HTN, Obesity
Treatment(s) PTA: Reports: None
Associated Symptoms: Reports: None

Review of Systems

Review Of Systems: Completed. All Systems Otherwise Negative

Past Medical/Family/Social Hx
Medical History: Reports: No Medical History
Family History:
Family History (Last Updated 07/01/19 @ 12:28 by Kimberly Elkins)
Diabetes
Mother

Smoking Status: Never Smoker
Drugs Abused: Reports: None

Physical Exam

General
General Appearance: Alert, No Acute Distress

Skin
Skin: Dry, Intact, Pink

Head
Head: Normocephalic, Atraumatic

Eye
Eye: Normal Conjunctiva

ENT
ENT: Oral Mucosa Moist

Neck
Neck: Supple, Trachea Midline

Chest Wall
Chest Wall: Normal Inspection, Symmetric Chest Wall Rise

Cardiovascular
Cardiovascular: Regular Rate, Normal Rhythm

Respiratory
Respiratory: Non-labored Respirations

Back
Back: Normal ROM

 Musculoskeletal
Musculoskeletal: Normal ROM

Neurological Exam
Neurological: A/O x4
Psychiatric: Cooperative

Medical Decision Making

MDM Narrative

Patient advised to buy a manual cuff in the appropriate size
Continue medications as prescribed
Advised her to start a whole food diet. Instructed her if it has a mother or grows in the dirt then she can eat it. Leave processed foods alone!

Sepsis Event Note

Evaluation
Sepsis screening result: No Definite Risk

Clinical Impression:
Hypertension

Disposition: Home, Self-Care/Family Care

Additional Instructions:
Continue her medication as directed by your primary care provider
Focus on eating whole foods (if it has a mother or grows in the dirt then you can eat it)
Exercise daily. Start with a 15 minutes walk and increase until you are walking briskly at least 30 minutes every day

CPT code : 99282

I10 – Hypertension